Basic Information
| Provider Information | |||||||||
| NPI: | 1790783454 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLATCHFORD | ||||||||
| FirstName: | GARNET | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DAVIS | ||||||||
| OtherFirstName: | GARNET | ||||||||
| OtherMiddleName: | JEAN | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9850 NICHOLAS ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681142186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023431122 | ||||||||
| FaxNumber: | 4023431177 | ||||||||
| Practice Location | |||||||||
| Address1: | 9850 NICHOLAS ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681142186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023431122 | ||||||||
| FaxNumber: | 4023431177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208C00000X | 17044 | NE | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
ID Information
| ID | Type | State | Issuer | Description | 47053395014 | 05 | NE | MEDICAID |